Complex suicide with homemade nicotine patches.

Suicide by self-poisoning is rather common around the world. This paper presents an exceptional complex suicide in which nicotine was applied in the form of self-made patches soaked with an extraction from fine-cut tobacco. In addition, the 51-year-old suicide victim took a lethal dose of diphenhydramine. Toxicological analysis also revealed the presence of tetrazepam in subtherapeutic concentrations. The scene of death suggested an autoerotic accident at first, as the body was tied with tapes, cables and handcuffs. As a result of the entire investigations, the fatality had to be classified as a suicidal intoxication by nicotine and diphenhydramine.

Comparison of direct and indirect alcohol markers with PEth in blood and urine in alcohol dependent inpatients during detoxication.

The importance of direct and indirect alcohol markers to evaluate alcohol consumption in clinical and forensic settings is increasingly recognized. While some markers are used to prove abstinence from ethanol, other markers are suitable for detection of alcohol misuse. Phosphatidyl ethanol (PEth) is ranked among the latter. There is only little information about the correlation between PEth and other currently used markers (ethyl glucuronide, ethyl sulfate, carbohydrate deficient transferrin, gamma-glutamyl transpeptidase, and methanol) and about their decline during detoxification. To get more information, 18 alcohol-dependent patients in withdrawal therapy were monitored for these parameters in blood and urine for up to 19 days. There was no correlation between the different markers. PEth showed a rapid decrease at the beginning of the intervention, a slow decline after the first few days, and could still be detected after 19 days of abstinence from ethanol.

Fatal doxepin intoxication--suicide or slow gradual intoxication?

The differentiation of intoxication courses is one of the most difficult challenges for forensic pathologists and toxicologists. The case of a 52-year-old female inpatient of a psychiatric clinic with multiple medications who died from doxepin intoxication is reported. Concentrations of doxepin metabolites and isomers, pharmacokinetic modelling and genotyping of the doxepin-metabolizing cytochrome P450 (CYP) enzymes led to the following conclusion: the lethal doxepin concentration of 2100 ng/mL was more likely to have been reached due to drug interactions and genetic peculiarities leading to a reduction of the metabolic capacity and not by an acute (suicidal) overdose.

Detection of ethyl glucuronide in blood spotted on different surfaces.

This study aims to show that sensitive detection of ethyl glucuronide in dried blood spotted onto various surfaces after a period of 24h is feasible. At present, there is insufficient information how tightly ethyl glucuronide (EtG) binds to various materials and how easily it can be eluted. 4ml aliquots of blood samples obtained from seven volunteers after consumption of alcoholic beverages were applied to six different surfaces. After drying and a 24h-storage at 20±2°C the samples were re-dissolved in water, and EtG was subsequently analyzed by a LC-MS Paul-type ion trap. A comparison was made between dried and corresponding fluid samples. EtG was detectable in all subjects' samples following consumption of alcohol. EtG was also detectable after a storage time of four weeks at 4°C in whole blood that had been preserved with EDTA. EtG was detectable in all samples dried on different surfaces and its concentration remained relatively constant irrespective of the particular condition of the material. Detection of EtG in blood spots from the scene may indicate recent alcohol consumption in cases where collection of blood remained undone or could not be performed.

Tooth aspiration: its relevance in medicolegal autopsies.

Tooth aspiration in adulthood is an uncommon autopsy finding. The paper presents two cases in which maxillary incisors had been avulsed and inhaled during hospital treatment and in the course of maxillofacial trauma, respectively. In the first case, repeated attempts to remove the aspirated tooth by means of flexible bronchoscopy led to perforation of the bronchial wall with consecutive bleeding into the deep airways and fatal asphyxia. In the second case, the fact of tooth aspiration remained undetected throughout the 3-day survival time until death from craniocerebral trauma. The paper points out the forensic aspects of tooth aspiration against the background of the relevant clinical literature.

Experimental simulation of reentry shots using a skin-gelatine composite model.

A bullet that has passed in and out of one body segment may continue its way into another part of the body causing a second entrance ("reentry") wound, which is often said to have an atypical and sometimes confusing appearance. To analyze this problem in a systematical approach, 9-mm Parabellum full metal-jacketed projectiles were fired at skin-gelatine composite models simulating the consecutive passage of a bullet through two parts of a body. When there was a distance between the two segments, the primary exit and the reentry skin wounds did not show any distinctive features differing from usual gunshot injuries. In the case of contact between exit and reentry site, the corresponding skin wounds resembled each other as both had central tissue defects surrounded by abrasion areas. The subsequent investigation of the simulant revealed that skin particles from both the exit and the adjacent reentry site had been displaced in the direction of the shot along the whole bullet track of the second segment. The morphological findings are presented and discussed with respect to the pertinent literature, and possible physical ballistic explanations are suggested.

Selective detection of phosphatidylethanol homologues in blood as biomarkers for alcohol consumption by LC-ESI-MS/MS.

A new validated method for the quantitation of the abnormal phospholipid phosphatidylethanol (PEth)--a biomarker for ethanol uptake--has been developed by LC-ESI-MS/MS following miniaturised organic solvent extraction and reversed phase chromatography with phosphatidylbutanol (PBut) as internal standard. PEth homologues with two fatty acid substituents-PEth 18:1/18:1, PEth 16:0/16:0-were determined in post-mortem blood collected from heavy drinkers at autopsy and also in whole blood samples from a volunteer after a single 60 g-dose of ethanol. Furthermore, PEth 18:1/16:0 or its isobaric isomer PEth-16:0/18:1 was detected. In comparison to previous high-performance liquid chromatography (HPLC) methods with evaporative light scattering detection (ELSD), the LC-MS/MS-method is more sensitive--with a limit of detection below 20 ng/ml--and more selective for single PEth homologues, while ELSD has been used for detection of the sum of PEth homologues with approximately 10 times less sensitivity. LC-MS/MS enables monitoring of PEth homologues as biomarkers for harmful and prolonged alcohol consumption as with HPLC/ELSD earlier, where PEth is measurable in blood only after more than 50 g ethanol daily intake for more than 2 weeks. Because of its higher sensitivity, there is a potential to detect single heavy drinking by LC-MS/MS, when PEth is formed in very low concentrations. This opens a new field of application of PEth to uncover single or multiple heavy drinking at a lower frequency and with a larger window of detection in blood than before by HPLC/ELSD or by use of other direct markers, e.g. ethyl glucuronide or ethyl sulfate.

Suicidal poisoning with mercaptodimethur-morphological findings and toxicological analysis.

In the western countries, the number of fatal intoxications with plant protecting agents has decreased to some extent due to laws restricting the use of highly toxic pesticides like halogenated hydrocarbons. Nevertheless, in consideration of the easy availability of most plant protectants, the small fraction of such fatalities among suicides and intoxications is astonishing. An 80-year-old woman died of an intoxication with methiocarb (mercaptodimethur), a carbamate type pesticide and as such a reversible inhibitor of the acetylcholinesterase. The case is presented because it is the first explicit report on a fatal poisoning of a human with methiocarb. The methiocarb concentrations detected were 6,100 microg/g in stomach content, 4.0 microg/ml in heart blood, 11 microg/g in kidney, 1.9 microg/ml in urine, 25 microg/g in liver, 2 microg/g in bile and 2.5 microg/g in brain tissue.

Non-diagnosed pulmonary hyalinizing granuloma (PHG) as a cause of sudden unexpected death.

Pulmonary hyalinizing granuloma (PHG), a very rare benign tumour of the lungs, was first reported in 1977. We present a PHG of a 32-year-old woman from Yemen who collapsed 1 day after her arrival in Germany. Tuberculosis was suspected and the health authorities nearly closed part of one of the major international airports in Europe. However, this drastic measure was avoided by autopsy and a correct interpretation of the solid-elastic and well-circumscribed lung tumour as not characteristic for tuberculosis. Although the final diagnosis of PHG was only achieved after histology, this case strongly illustrates the necessity of a profound morphological training of forensic physicians.

Wischnewsky's spots in an ectopic stomach.

Wischnewsky's spots in the mucosa of the stomach have been a well-known sign of death due to hypothermia for many years. Furthermore it is reported that those spots can rarely be found in the esophagus as well. We now report on a case concerning a 93-year-old woman who presented an ectopic stomach with erosions of the mucosa in the intrathoracic part of the stomach that were assessed as Wischnewsky's spots. When she was found dead in her flat, she was completely undressed and showed an injury to the head. The autopsy findings are presented and discussed in view of a possible genesis and pathophysiology of Wischnewsky's spots.

Fatal rupture of an undiagnosed aneurysm of the splenic artery--medico-legal implications.

Aneurysms of the visceral arteries are a rather common feature appearing in 0.1-2% of the population. The clinical relevance of those anomalies varies a lot. The wide range of descriptions reaches from asymptomatic cases to fatalities in particular due to haemorrhages. The latter will be discussed in a case report concerning a 60-year-old man who collapsed at his work place and died 4 h after admission to the intensive care unit of a hospital nearby. The ruptured aneurysm remained undiagnosed in hospital and was found by autopsy. The case is presented and discussed in view of medico-legal questions.